Methods for promoting intrinsic activation in single chamber implantable cardiac pacing systems

ABSTRACT

Cardiac pacing methods for an implantable single chamber pacing system, establish an offset rate for pacing at a predetermined decrement from either a baseline rate (i.e. dictated by a rate response sensor), or an intrinsic rate. Pacing maintains the offset rate until x of y successive events are paced events, at which time the offset rate is switched to the baseline rate for pacing over a predetermined period of time. Following the period, if an intrinsic event is not immediately detected, within the interval of the offset rate, the rate is switched back to baseline for pacing over an increased period of time. Some methods establish a preference rate, between the offset and baseline rates, wherein an additional criterion, for switching from the offset rate to the baseline rate, is established with respect to the preference rate.

RELATED APPLICATION

This application is a continuation of U.S. patent application Ser. No.13/932,782, filed Jul. 1, 2013 (now issued as U.S. Pat. No. 8,755,884)entitled “METHODS FOR PROMOTING INTRINSIC ACTIVATION IN SINGLE CHAMBERIMPLANTABLE CARDIAC PACING SYSTEMS”, herein incorporated by reference inits entirety.

TECHNICAL FIELD

The present invention pertains to cardiac pacing methods and moreparticularly to pacing methods that promote intrinsic activation ofventricular depolarization to preserve natural conduction and increasesystem efficiency in single chamber implantable cardiac pacing systems.

BACKGROUND

The traditional implantable cardiac pacemaker includes a pulse generatordevice to which one or more flexible elongate lead wires are coupled.The device is typically implanted in a subcutaneous pocket, remote fromthe heart, and each of the one or more lead wires extends therefrom to acorresponding electrode, coupled thereto and positioned at a pacingsite, either endocardial or epicardial. Mechanical complications and/orMRI compatibility issues, which are sometimes associated with elongatelead wires and well known to those skilled in the art, have motivatedthe development of cardiac pacing systems that are wholly containedwithin a relatively compact package for implant in close proximity tothe pacing site, for example, within the right ventricle (RV) of theheart. With reference to FIGS. 1A-B, such a system 100 is illustrated,wherein pace/sense electrodes 111, 112 are formed on an exterior surfaceof a capsule 101 that hermetically contains a pulse generator 103 (shownin FIG. 1B via a block diagram). FIG. 1A further illustrates tinemembers 115 mounted to an end of capsule 101, in proximity to electrode111, in order to secure electrode 111 against the endocardial surface ofRV, and electrode 112 offset distally from electrode 111. Capsule 101 ispreferably formed from a biocompatible and biostable metal such astitanium overlaid with an insulative layer, for example, medical gradepolyurethane or silicone, except where electrode 112 is formed as anexposed portion of capsule 101. An hermetic feedthrough assembly (notshown), such as any known to those skilled in the art, couples electrode111 to pulse generator 103 contained within capsule 103.

With further reference to FIGS. 1A-B, those skilled in the art willappreciate that system 100, via electrodes 111, 112, has the capabilityto sense intrinsic ventricular depolarization (i.e. R-waves) and, in theabsence of the intrinsic depolarization, to apply stimulation pulses tothe RV in order to create paced ventricular depolarization. Pulsegenerator 103 of system 100 further includes rate response sensor 135that monitors a patient's general level of physical activity todetermine an appropriate pacing rate for the patient. Examples ofsuitable rate response sensors include, without limitation, a forcetransducing sensor, such as a piezoelectric crystal like that describedin commonly assigned U.S. Pat. No. 4,428,378 Anderson et al.; an AC orDC accelerometer like those described in commonly assigned U.S. Pat. No.5,957,957 to Sheldon; and any type of physiological sensor known in theart, such as those that measure minute ventilation, QT intervals, bloodpressure, blood pH, blood temperature, blood oxygen saturation etc.Numerous cardiac pacing methods that employ such RV pacing and sensingand physical activity monitoring are known in the art, for example, asdisclosed in commonly assigned U.S. Pat. No. 4,428,378 (to Anderson etal.), U.S. Pat. No. 6,772,005 (to Casavant et al.), and U.S. Pat. No.5,522,859 (to Stroebel et al.), as well as U.S. Pat. No. 5,374,281 (toKristall et al.) and U.S. Pat. No. 6,122,546 (to Sholder et al.). Manyof the aforementioned disclosures address the desire to limit the amountof pacing stimulation delivered from implantable pacemakers,particularly right ventricular stimulation in patients that have intactAV conduction (through the AV node, from the sinus node in the rightatrial wall to the right and left bundle branches in the ventricularseptum), in order to preserve the patient's natural conduction andincrease pacemaker efficiency. However, the relatively moresophisticated pacing methods that are geared toward preserving thepatient's natural conduction rely upon dual chamber sensing as thesemethods were developed in concert with the evolution of pacemakersystems from single chamber to dual chamber. Thus, there is a need fornew cardiac pacing methods that preserve natural conduction and increasesystem efficiency for single chamber implantable pacing systems, ofeither the traditional type or the relatively compact type, like thatshown in FIGS. 1A-B.

SUMMARY

Embodiments of the present invention include single chamber pacingsystems that employ the methods disclosed. According to some methods ofthe present invention, an offset rate for pacing is establishedaccording to a predetermined decrement of either a baseline rate or agreater of the baseline rate and an intrinsic rate, wherein the baselinerate is established according to input from one or more rate responsesensors. Pacing stimulation is applied when necessary to maintain theoffset rate (for example, as determined via sensing for intrinsicventricular depolarization), until x of y successive events (x>1 andy≧x) are paced events, at which time the offset rate is switched to thebaseline rate and pacing stimulation at the baseline rate is appliedover a predetermined period of time. According to some methods, thepredetermined period of time may be shortened in response to thedetection of intrinsic events occurring at a rate greater than thebaseline rate. At the end of the predetermined period of time, sensingfor intrinsic events resumes, and, according to some preferred methods,if an intrinsic event is not immediately detected, within the timeinterval necessary to at least maintain the offset rate, the rate isswitched back to the baseline rate for pacing over an increased periodof time.

According to some preferred methods, the predetermined decrement may beincreased to establish an even lower offset rate, when a preference rateis established in between the baseline and offset rates. Theestablishment of the preference rate is associated with inclusion ofanother switching criterion in addition to the aforementioned x of ycriterion. When the preference rate is employed, a switch from theoffset rate to the baseline rate occurs, even if the aforementioned x ofy criterion is not met, when successive intrinsic events meet anotherpredetermined criterion with respect to the preference rate, forexample, when a detected measure of central tendency for successiveintrinsic events, over a predetermined interval, falls below thepreference rate.

BRIEF DESCRIPTION OF THE DRAWINGS

The following drawings are illustrative of particular embodiments andmethods of the present invention and therefore do not limit the scope ofthe invention. The drawings are not to scale (unless so stated) and areintended for use in conjunction with the explanations in the followingdetailed description. Methods of the present invention will hereinafterbe described in conjunction with the appended drawings wherein likenumerals denote like elements, and

FIGS. 1A-B are schematics providing context for methods of the presentinvention;

FIG. 2 is a flowchart outlining some methods of the present invention;

FIGS. 3A-B are plots illustrating examples that correspond to the flowchart of FIG. 2;

FIG. 4 is a flowchart outlining some alternate methods of the presentinvention; and

FIG. 5 is a plot illustrating an example that corresponds to the flowchart of FIG. 4.

DETAILED DESCRIPTION

The following detailed description is exemplary in nature and is notintended to limit the scope, applicability, or configuration of theinvention in any way. Rather, the following description providespractical examples, and those skilled in the art will recognize thatsome of the examples may have suitable alternatives.

With reference to FIG. 1A, pacing system 100 is shown wholly implantedagainst an endocardial surface within the right ventricle RV for rightventricular pacing and stimulation. However, methods of the presentinvention may be employed by any single chamber pacing system (eitherthe traditional type or the relatively compact type) when implantedendocardially or epicardially, for either ventricular pacing andsensing, or atrial pacing and sensing (left or right chambers). Thus theterm “intrinsic events” used in the following description can designateeither ventricular or atrial depolarization signals. FIG. 1B is a blockdiagram of the electrical components of pulse generator 103 including amicrocomputer circuit 148, known to those skilled in art, wherein amicroprocessor element thereof may be preprogrammed to direct pulsegenerator 103 to execute any of methods disclosed herein. Although notshown, an appropriate implantable battery power source is preferablyincluded within capsule 101 to power the electrical components of pulsegenerator 103.

FIG. 2 is a flowchart outlining some methods of the present invention,whereby baseline and offset rates, established via dynamic input fromrate response sensor 135 and electrodes 111, 112, are utilized by pacingsystem 100 to provide adequate pacing support to a patient whileminimizing any unnecessary pacing stimulation. In a first step 200 ofthe outlined method, the baseline rate is dynamically established bymeans of input from rate response sensor 135; that is, the rate responsesensor, which may include one or more activity or physiologic sensors,such as those described above, tracks a level of patient activity andprovides input concerning an appropriate pacing rate to support thepatient at any given time, which appropriate rate is designated as thebaseline rate. Step 200 further includes establishment of thecorresponding offset rate, which is lower than the baseline rate andgenerally tracks the baseline rate at a predetermined decrement thereof,according to some methods. However, according to some alternate methods,if an intrinsic rate, as sensed by electrodes 111, 112, exceeds thebaseline rate, the offset rate is established by a predetermineddecrement of the sensed intrinsic rate. According to some methods, thepredetermined decrement may be absolute or percentage based, accordingto rate (bpm) or interval (ms), or any combination thereof; someexamples are presented in Table 1. In Table 1, the term ‘tracked rate’is used to generically designate either the baseline rate or theintrinsic rate, depending upon the method employed—baseline rate, if thefirst of the aforementioned methods is employed or if the baseline rateexceeds the intrinsic rate, when the latter, alternative method isemployed; and intrinsic rate, if the latter method is employed and theintrinsic exceeds the baseline.

TABLE 1 Offset Rate when tracked rate = 60 beats Offset Rate when OffsetRate when Predetermined per minute tracked rate = 100 tracked rate = 175rate (1000 ms beats per minute beats per minute decrement intervals)(600 ms intervals) (342 ms intervals) subtract 10 bpm 50 bpm 90 bpm 165bpm subtract 12 bpm 48 bpm 88 bpm 163 bpm subtract 15 bpm 45 bpm 85 bpm160 bpm subtract 20 bpm 40 bpm 80 bpm 155 bpm subtract 25% bpm 45 bpm 75bpm 131 bpm add 25% ms 48 bpm 80 bpm 140 bpm (1250 ms (750 ms intervals)(427 ms interval) intervals) add 25% ms- 50 bpm 85 bpm 160 bpm 50 ms(1200 ms (700 ms intervals) (377 ms intervals) intervals) add 30% ms 46bpm 76 bpm 134 bpm (1300 ms (780 ms intervals) (445 ms intervals)intervals) Note: the last three rate decrements are presented in termsof beat-to-beat intervals in units of milliseconds.

In steps 202 and 204 of FIG. 2, sensing intrinsic events and onlyapplying pacing stimulation to create paced events that maintain thelower offset rate allows the patient's natural conduction to persistuntil such time that the method determines pacing stimulation isnecessary to support the patient. According to decision point 206 ofFIG. 2, this time is reached when x of y successive events are pacedevents, wherein x is always greater than one and y may be equal to x orgreater than x. When this x of y criterion is met, the pacing rateswitches from the offset rate to the baseline rate for pacing over apredetermined period of time, according to step 231. Two examples of thex of y switching criterion are shown in FIGS. 3A-B.

FIGS. 3A-B are plots of rate vs. time wherein open boxes representintrinsic events, closed circles represent paced events, and dashedlines denote the established baseline and offset rates. (Note that,according to the aforementioned alternate methods, the baseline rate inthe Figures could alternately be the intrinsic rate, if and when theintrinsic rate is greater that the baseline rate.) FIG. 3A illustrates aswitching criterion of x=2 and y=3 and FIG. 3B illustrates a switchingcriterion of x=8 and y=8. FIGS. 3A-B further illustrate a predeterminedperiod of time of approximately one minute, over which pacingstimulation is applied at the baseline rate. However, according to somemethods, if, before the end of the predetermined period of time,intrinsic events occurring at a greater rate are detected, the pacingstimulation is aborted, thereby effectively shortening the predeterminedperiod of time. In either case, at the end of the predetermined period,if intrinsic events are immediately detected at a rate that at leastcorresponds to the offset rate, sensing continues per step 202 of FIG.2, as shown in FIGS. 3A-B. Alternately, with reference to decision point233 of FIG. 2, if, at the end of the predetermined period of time ofpacing, an intrinsic event is not immediately detected within the timeinterval necessary to at least maintain the offset rate, so that a pacedevent is created for maintenance of the offset rate, the method switchesthe rate back to the baseline rate for pacing over an increased periodof time, per step 239. Although not shown in FIG. 2, the methodpreferably includes a maximum limit on this increased period of time,for example, sixteen hours, so that subsequent increased periods oftime, if necessary, do not exceed maximum.

FIG. 4 is a flowchart modified from that shown in FIG. 2 to outline yetfurther methods of the present invention. The methods outlined in FIG. 4differ from those outlined in FIG. 2 in that an additional rate, calledthe preference rate, is established, per step 400, and an additionalswitching criterion, corresponding to the preference rate is included atdecision point 406. According to methods outlined in FIG. 4, even if xof y paced events are not detected, the switch, per step 231, may bemade, if the criterion at decision point 406 is met, for example asillustrated in the plot FIG. 5.

FIG. 5 is a plot of rate vs. time, wherein open boxes representintrinsic events and closed circles paced events, like the plots ofFIGS. 3A-B. The dashed lines in FIG. 5 denote the established baseline,preference and offset rates. The preference rate, which is between thebaseline rate and the offset rate allows for a greater predetermineddecrement, or a lower offset rate, without sacrificing pacing support inthe event of chronotropic incompetence, which, according to decisionpoint 406 of FIG. 4, corresponds with the successive intrinsic eventsmeeting a predetermined criterion with respect to the preference rateover a predetermined interval, as designated by the bracket in FIG. 5.This criterion may be x of y intrinsic events (x>1 and y≧x) fallingbelow the preference rate, although remaining above the offset rate, orsome measure of central tendency, like mean, median or mode, ofsuccessive intrinsic events over a predetermined interval being lessthan the preference rate, although greater than the offset rate.Establishing the lower offset rate with the protection of the preferencerate, according to the methods of FIG. 4, can allow normal/physiologicalmicro rate changes that temporarily slow the intrinsic heart rate (i.e.those associated with respiration changes) to be tolerated withoutcreating paced events. With reference back to Table 1, the sameexemplary means used to establish the offset rate may be used toestablish the preference rate, according to some methods.

Finally, with further reference to the plots of FIGS. 3A-B and 5,according to some methods, at least one pacing stimulation pulse at arate between either the offset rate or the preference rate and thebaseline rate (as designated by grey circles) is applied just prior tothe switch to the baseline rate. Whether or not such transition, or“rate smoothing” pulses are applied, and the number of pulses applieddepends upon the magnitude of the difference between the two rates atthe time the switch is made.

In the foregoing detailed description, the invention has been describedwith reference to specific methods. However, it may be appreciated thatvarious modifications and changes can be made without departing from thescope of the invention as set forth in the appended claims.

We claim:
 1. A single chamber cardiac pacing system configured to bewholly implanted in a patient's heart, the system including: implantableelectrodes; a pulse generator coupled to the electrodes; one or morerate response sensors; means for establishing a baseline rate for pacingstimulation according to input from the one or more rate responsesensors; means for establishing an offset rate for pacing stimulation,the offset rate being lower than the baseline rate, wherein a change inone of the baseline rate or the offset rate is generally tracked by theother of the offset rate or the baseline rate such that a differencebetween the baseline rate and the offset rate remains substantiallyconstant over time; means for sensing for intrinsic cardiac events bymeans of the implanted electrodes; means for applying a pacingstimulation pulse by means of the implanted electrodes, responsive to anintrinsic event not being sensed within a time interval necessary to atleast maintain the offset rate, the applied pacing stimulation pulsecreating a paced event to maintain the offset rate; means for switchingfrom the offset rate to the baseline rate and triggering pacing at thebaseline rate over a predetermined period of time, responsive to x of ysuccessive cardiac events being paced events, x being greater than oneand y being greater than or equal to x; and wherein the offset rate isestablished according to a predetermined decrement of one of: thebaseline rate; and a greater of the baseline rate and an intrinsic heartrate, the intrinsic heart rate determined according to prior sensedintrinsic events.
 2. The system of claim 1, wherein the predeterminedperiod of time is shortened in response to detection of intrinsic eventsoccurring at a rate that is greater than the baseline rate.
 3. Thesystem of claim 1, further comprising means for: establishing apreference rate that falls between the baseline rate and the offsetrate; and wherein the switching means switches from the offset rate tothe baseline rate and triggers pacing at the baseline rate over thepredetermined period of time, responsive to the rates of successiveintrinsic events, over a predetermined interval, even if greater thanthe offset rate, meeting a criterion with respect to the preferencerate, the criterion being one of: x of y successive intrinsic eventsfalling below the preference rate over the predetermined interval, xbeing greater than one and y being greater than or equal to x; and ameasure of central tendency of the rates of successive intrinsic eventsfalling below the preference rate over the predetermined interval. 4.The system of claim 3, wherein the preference rate is establishedaccording to a predetermined decrement of the baseline rate, thepredetermined decrement being one or a combination of: a fixed beats perminute decrement, a percentage beats per minute decrement, a fixedinterval increment, and a percentage interval increment.
 5. The systemof claim 3, further wherein the switching means triggers at least onepacing stimulation pulse at a rate between the preference rate and thebaseline rate, responsive to the rates of successive intrinsic eventsmeeting the criterion with respect to the preference rate, and justprior to the corresponding switch to the baseline rate.
 6. The system ofclaim 3, wherein, at the end of the predetermined period of time,responsive to an intrinsic event not being detected within the timeinterval necessary to at least maintain the offset rate, the switchingmeans switches back to the baseline rate and pacing at the baseline rateover a another predetermined period of time that is increased from theprevious predetermined period.
 7. The system of claim 1, wherein theoffset rate is established according to a predetermined decrement of thebaseline rate, the predetermined decrement being one or a combinationof: a fixed beats per minute decrement, a percentage beats per minutedecrement, a fixed interval increment, and a percentage intervalincrement.
 8. The system of claim 1, wherein the switching meanstriggers at least one pacing stimulation pulse at a rate between theoffset rate and the baseline rate, just prior to the switch to thebaseline rate.
 9. The system of claim 1, wherein x equals two and yequals three or x and y both equal eight.
 10. The system of claim 1,wherein the predetermined period of time is equal to approximately oneminute.
 11. The system of claim 1, wherein the substantially constantdifference over time is maintained by decrementing one of the baselinerate or the offset rate by a value that corresponds to the other of theoffset rate or the baseline rate.
 12. The system of claim 1, wherein thesubstantially constant difference over time is maintained byincrementing one of the baseline rate or the offset rate by a value thatcorresponds to the other of the offset rate or the baseline rate.